Proposed new diagnoses of anxious depression and bodily stress syndrome in ICD-11-PHC: an international focus group study. [JOURNAL ARTICLE]

Fam Pract 2012 Jul 28.

BACKGROUND: The World Health Organization is revising the primary care classification of mental and behavioural disorders for the International Classification of Diseases (ICD-11-Primary Health Care (PHC)) aiming to reduce the disease burden associated with mental disorders among member countries.

METHODS: Qualitative study with focus groups of primary health-care workers, using standard interview schedule after draft ICD-11-PHC criteria for each proposed entity was introduced to the participants.

RESULTS: Nine focus groups with 4-15 participants each were held at seven locations: Austria, Brazil, Hong Kong, New Zealand, Pakistan, Tanzania and United Kingdom. There was overwhelming support for the inclusion of anxious depression, which was considered to be very common in primary care settings. However, there were concerns about the 2-week duration of symptoms being too short to make a reliable diagnosis. BSS was considered to be a better term than medically unexplained symptoms but there were disagreements about the diagnostic criteria in the number of symptoms required.

CONCLUSION: Anxious depression is well received by primary care professionals, but BSS requires further modification. International field trials will be held to further test these new diagnoses in draft ICD-11-PHC.

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Notes and related posts:

ICD-10 PHC (sometimes written as ICD-10-PHC or ICD10-PHC or ICD-10 PC), is a simplified version of the WHO’s ICD-10 chapter for mental and behavioural disorders for use in general practice and primary health care settings. This system has rough but not exact equivalence to selected of the mental disorders in the core ICD-10 classification.

The ICD-10 PHC includes and describes 26 disorders commonly managed within primary care as opposed to circa 450 classified within Chapter V of ICD-10.

Professor, Sir David Goldberg, M.D., Emeritus Professor, Institute of Psychiatry, King’s College, London, is a member of the DSM-5 Mood Disorders Work Group. Prof Goldberg also chairs the Consultation Group for Classification in Primary Care that is making recommendations for the mental and behavioural disorders for ICD-11 PHC.

The majority of patients with mental health problems are diagnosed and managed by general practitioners in primary care – not by psychiatrists and mental health specialists. ICD-10 PHC is used in developed and developing countries in general medical settings and also used in the training of medical officers, nurses and multi purpose health workers.

Note: The list of proposed categories in the editorial above has been superseded by the list in Chapter 2 of this book, below. (Source: Prof D Goldberg, who stresses these are draft proposals and subject to revision in the light of field trial results).

Stakeholders have been obliged to submit feedback without the benefit of scrutinizing reliability data or any other information about the field trials APA had intended/may still intend/does not intend publishing.

“…DSM-5, unlike DSM-IV, invited comments from the world, and the work groups and task force considered every one of the more than 25,000 comments received and conducted further research where indicated.”

Following the first posting of draft proposals, out on review for ten weeks in spring 2010, APA reported receiving around 8,600 submissions; for the second review, around 2,120. I’m curious about this figure of “25,000 comments.”

I’ve asked Dr Scully, will he account for that figure of a total of 25,000 comments so far? I’ll update if Dr Scully responds.

According to Task Force Vice-Chair, Darrel Regier, M.D., the specific diagnostic categories that received the most comments during the second public review and feedback exercise had been the sexual and gender identity disorders, followed closely by somatic symptom disorders and anxiety disorders.

Following closure of the two previous public reviews, APA issued statements and articles. I will update with any statements that are released.

What now?

Content on the DSM-5 Development site (proposals for changes to categories, criteria, rationales, severity specifiers etc) is now frozen.

The site will not be updated to reflect any revisions and edits made between June 15 and submission of final texts, later this year, for approval by APA Board of Trustees.

The remainder of the development process is set out on the Home Page under “Next Steps” and in the APA Board Materials Packet – December 10-11, 2011. This document sets out the DSM-5 Development program from December 2011 until May 2013:

According to APA’s newly published and highly restrictive DSM-5 Permissions Policy – following closure of this third and final public review and comment period, content of DSM-5 will be under strict embargo until the manual is published.

Final text is expected to be presented to APPI, the APA’s publishing arm, by December 31 for May 2013 publication.

I shall continue to update this site with any developments and with media coverage and commentary.

In ‘1984’, George Orwell introduced the term ‘Newspeak’ – the abuse of language by totalitarian bureaucracies to create an upside down, looking glass world of misinformation. He was probably inspired by ‘Pravda,’ the Soviet Union’s propaganda paper that literally means ‘truth’ in Russian but was famous for publishing everything but.

This brings us to the American Psychiatric Association. Its medical director recently justified the astounding $25 million APA has already spent on DSM 5 (5 times the cost of DSM IV) with a curious claim- DSM 5 was so exorbitantly expensive because it was so unprecedentedly open. This classic Newspeak kills two truth birds with one stone — DSM 5 didn’t waste a huge amount of money and DSM 5 didn’t fail because it was a closed shop. The futile hope is that black will become white if only you say it enough times.

In fact, it is very cheap to run an open process — and very expensive to run a PR disinformation campaign. It cost me nothing but an hour’s time to write this blog. How much, I wonder, will it cost APA to pay off GYMR (its high powered public relations producer of newspeak pravda) to defend its indefensible claims that DSM 5 is an open process and that it can meet its unrealistic timetable with a reliable manual?

Here is a top 10 list of great moments in the history of APA ‘openness’.

1) APA forces work group members to sign confidentiality agreements to protect DSM 5 ‘intellectual property’.

2) DSM 5 does a confidential and super-secret ‘scientific’ review of itself- real science is never secret.

3) APA rebuffs calls from 51 mental health associations for an open and independent scientific review.

4) APA’s legal office tries to stifle criticism and censor the internet using inappropriate and bullying threats of trademark litigation.

5) APA plans to steeply jack up licensing costs for use of DSM criteria sets in order to recoup its unaccountably huge investment on its ‘intellectual property’.

6) DSM 5 only reluctantly engages on the issues and instead stonewalls criticism with offensive and defensive tactics.

7) The original DSM 5 plan for field trials included no prior public viewing of criteria sets and no period for public comment. These are added only under heavy outside pressure.

8) DSM 5 publishes no aggregations of key areas of concern identified during public reviews; doesn’t respond publicly to them and there is no indication that public input has had any impact whatever on DSM 5.

9) The APA ‘charitable’ foundation (meant to provide open public education) is named by a watchdog group as the 7th worst charity in all of the US.

10) APA promises to post a complete set of DSM 5 reliability data in time to allow comments during the final period of public review- but fails to do so.

And this is just a taster. At least a dozen reporters have spontaneously mentioned to me that never in their careers have they encountered anything so byzantine as the APA press office. And dozens of APA members have emailed their frustration at not being able to get a straight (or any) answer from a staff whose salaries are paid by their membership dues.

It requires lots of time, money, and brain power to create ‘pravda.’ Perhaps this explains why everything connected with DSM 5 is always so late and so expensive and why a high flying hired gun like GYMR is needed to run its interference. The real truth is fast, cheap, and very simple to explain.

ACA President Don W. Locke has sent the American Psychiatric Association a letter providing final comments for the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Based on comments from ACA members and the ACA DSM Task Force, the letter acknowledges useful changes that had been made to previous drafts of the DSM-5: the development of the Cultural Formulation Outline, reversing the pathologizing of normal bereavement, and limiting the expansion of personality disorder types. ACA also calls for addressing the one-dimensional nature of the new Substance Use Disorder category and rejects the proposed dimensional assessments. Click here to view letter.

This is the third letter ACA has sent to the American Psychiatric Association providing feedback for the DSM-5. Click the links below to read the previous letters and a response from APA:

As you know, the Open Letter Committee of the Society for Humanistic Psychology and the Coalition for DSM-5 Reform have been following the development of DSM-5 closely.

We appreciate the opportunity for public commentary on the most recent version of the DSM-5 draft proposals. We intend to submit this brief letter via the dsm5.org feedback portal and to post it for public viewing on our website at http://dsm5-reform.com/

Since its posting in October 2011, the Open Letter to the DSM-5, which was written in response to the second version of the draft proposals, has garnered support from almost 50 mental health organizations and over 13,500 individual mental health professionals and others.

Our three primary concerns in the letter were as follows: the DSM-5 proposals appear to lower diagnostic thresholds, expanding the purview of mental disorder to include normative reactions to life events; some new proposals (e.g., “Disruptive Mood Dysregulation Disorder” and “Attenuated Psychosis Syndrome”) seem to lack the empirical grounding necessary for inclusion in a scientific taxonomy; newly proposed disorders are particularly likely to be diagnosed in vulnerable populations, such as children and the elderly, for whom the over-prescription of powerful psychiatric drugs is already a growing nationwide problem; and the increased emphasis on medico-biological theories for mental disorder despite the fact that recent research strongly points to multifactorial etiologies.

We appreciate some of the changes made in this third version of the draft proposals, in particular the relegation of Attenuated Psychosis Syndrome and Mixed Anxiety-Depression to the Appendix for further research. We believe these disorders had insufficient empirical backing for inclusion in the manual itself. In addition, given the continuing elusiveness of biomarkers, we are relieved to find that you have proposed a modified definition of mental disorder that does not include the phrase “underlying psychobiological dysfunction.”

Despite these positive changes, we remain concerned about a number of the DSM-5 proposals, as well as the apparent setbacks in the development process.

Our continuing concerns are:

• The proposal to include new disorders with relatively little empirical support and/or research literature that is relatively recent (e.g., Disruptive Mood Dysregulation Disorder)

• The lowering of diagnostic thresholds, which may result in diagnostic expansion and various iatrogenic hazards, such as inappropriate treatment and stigmatization of normative life processes. Examples include the newly proposed Minor Neurocognitive Disorder, as well as proposed changes to Generalized Anxiety Disorder, Attention Deficit/Hyperactivity Disorder, Pedophilia, and the new behavioral addictions.

• The perplexing Personality Disorders overhaul, which is an unnecessarily complex and idiosyncratic system that is likely to have little clinical utility in everyday practice.

• The development of novel scales (e.g., severity scales) with little psychometric testing rather than utilizing established standards.

In addition, we are increasingly concerned about several aspects of the development process. These are:

• Continuing delays, particularly in the drafting and field testing of the proposals.

• The substandard results of the first set of field trials, which revealed kappas below accepted reliability standards.

• The cancelation of the second set of field trials.

• The lack of formal forensic review.

• Ad hominem responses to critics.

• The hiring of a PR firm to influence the interpretation and dissemination of information about DSM-5, which is not standard scientific practice.

We understand that there have been recent attempts to locate a “middle ground” between the DSM-5 proposals and DSM-5 criticism. We believe that, given the extremity and idiosyncrasy of some of the proposed changes to the manual, this claim of a “middle ground” is more rhetorical and polemic than empirical or measured. A true middle ground, we believe, would draw on medical ethics and scientific standards to revise the proposals in a careful way that prioritizes patient safety, especially protection against unnecessary treatment, above institutional needs.

Therefore, we would like to reiterate our call for an independent scientific review of the manual by professionals whose relationship to the DSM-5 Task Force and/or American Psychiatric Association does not constitute a conflict of interest.

As the deadline for the future manual approaches, we urge the DSM-5 Task Force and all concerned mental health professionals to examine the proposed manual with scientific and expert scrutiny.

It is not only our professional standards, but also –and most importantly– patient care that is at stake. We thank you for your time and serious consideration of our concerns, and we hope that you will continue to engage in dialogue with those calling for reform of DSM-5.

Sincerely,

The DSM-5 Open Letter Committee of the Society for Humanistic Society, Division 32 of the American Psychological Association

A copy of my own comment is published below in text and PDF format. If you are unable to submit your own letter or short of time, please consider endorsing Mary Dimmock’s submission or one of the other submissions or one from last year with a note to say that although the criteria have been revised since last year, the underlying concerns remain.

I note that at June 14, APA has published no report on the results of the DSM-5 field trials. The majority of stakeholders wishing to provide feedback on this third release of draft proposals have no information on the make-up of the SSD study groups, the numbers studied within each of the three arms or the resulting data.

Stakeholders have been obliged to submit comment without the benefit of scrutiny of field trial results to inform their submissions. This is not acceptable.

For the first and second release of draft proposals, a 7 page “Disorders Description” document and a 14 page “Rationale/Validity Propositions/Justification of Criteria” document accompanied proposals and expanded on the website Proposals, Criteria, Rationale and Severity content for this category section. In the case of the latter, this included five pages of references to published and unpublished papers, including a number of papers authored or co-authored by members of the SSD Work Group. With the release of this third and final draft, no updated versions of these two documents were published that reflect significant revisions to SSD criteria between the second and third draft. The unrevised versions have been removed from the website.

Stakeholders have been denied access to the more expansive rationales and validity propositions set out within these two documents, the research papers that have been relied on and more detailed explanations for the revisions made to criteria between the second and third iterations in response to field trial results and internal/external input. If the Work Group considered these documents essential background information for the first and second drafts it is unreasonable not to have provided stakeholders with updated versions for this third draft.

The “Rationale/Validity Propositions/Justification of Criteria” document (as published May 4, 2011, for the second public review) states:

“…It is unclear how these changes would affect the base rate of disorders now recognized as somatoform disorders. One might conclude that the rate of diagnosis of CSSD would fall, particularly if some disorders previously diagnosed as somatoform were now diagnosed elsewhere (such as adjustment disorder). On the other hand, there are also considerable data to suggest that physicians actively avoid using the older 6 diagnoses because they find them confusing or pejorative. So, with the CSSD classification, there may be an increase in diagnosis.”